Peta Hickey was 43 and healthy when she died from an allergic reaction to IV contrast dye in May 2019.
The mother had no history of heart problems and had agreed to be part of a voluntary cardiac screening program run by her employer, Programme Skilled Workforce in 2019.
It involved undergoing a cardiac CT scan at FMIG Radiology in Monee Ponds.
When the doctor administered the IV contrast dye, Ms Hickey suffered an anaphylactic reaction.
The office manager called Triple Zero and paramedics arrived to care for her before taking her to the intensive care unit at the Royal Melbourne Hospital.
Ms Hickey did not regain consciousness and died eight days later.
Coroner Simon McGregor today ruled her death was “a result of substandard clinical judgement from doctors at the beginning and end of this programme, combined with a misalignment of incentives amongst the various business entities that facilitated the process”.
“It may be somewhat of an oversimplification, but the snapshot provided by this Inquest has revealed an industry putting profits over patients,” his findings read.
The inquest heard a series of medical failings contributed to her death.
Ms Hickey had never had a consultation with the doctor whose electronic signature was on the test referral.
He was paid by her employer to review scan results, yet claimed he claims he had no idea he was referring her.
The inquest also found that when she suffered the reaction to the contrasting dye the doctor in charge didn’t know how to respond.
Coroner McGregor has recommended a Commonwealth audit of radiology practices to see how many referrals are valid.
Ms Hickey’s family wants to see serious changes made to the industry and they are preparing to launch civil action against the doctors and entities that let her down.
“I have fought to find out what happened to Peta so our children aged two and eight at the time will in time be able to understand,” her partner, Richard Hickey, told 9News.
Maurice Blackburn lawyer Kathryn Booth said the case put “everybody on notice that invasive testing for asymptomatic patients is a risky business”.
“This is one of the worst cases of medical negligence I’ve seen in my career,” she said.